Annals of the Royal College of Surgeons of England (1975) vol 56 ASPECTS OF TREATMENT*
Cosmetic result
in
thyroid surgery
Demetrios Chavatzas MD MS Department of Surgery, Royal Postgraduate Medical School and Hammersmith Hospital, London
Summary In a series of 306 consecutive patients who had thyroid or parathyroid surgery for benign or malignant lesionis attention was paid to a technique in which particular emphasis was laid on meticulous haemostasis and suction drainage of the postoperative serosanguineous fluid. This not only reduced the morbidity associated with haematoma formation and infection but also contribuited to a good cosmetic result.
Introduction Haemorrhage and its complications associated with thyroid surgery appear so promninently in the surgical literature of the igth century that many surgeons, including Billroth', abandoned thyroidectomy. Other leading surgeons of the time such as Kocher and later Halsted, with their devotion and professional excellence, advanced the techniques and consolidated the place of this operation. Further progress has been made in more recent years by advances in our understanding of the physiology and vascular anatomy of the thyroid gland and the pathology and diagnosis of its disorders2,'. Nevertheless, among the complications postoperative bleeding with haematoma formation and infection continues to influence the results of the operation'.
I here report a series of 306 consecutive patients who had thyroid or parathyroid surgery for benign or malignant lesions and draw attention to the results of a technique in which particular emphasis is laid on careful haemostasis and suction drainage.
Technique The patient lies on the operating table with the neck extended'. After a Kocher collar incision, division of the platysma, and reflection of it with the skin flaps the strap muscles are identified, separated in the midline, and lifted with stay sutures, two for each side. With the sternomastoid retracted laterally, the ansa hypoglossi nerve is identified and preserved, while the strap muscles are divided between the stay sutures and the thyroid gland is thuis exposed. After a non-absorbable stay suture has been placed in each upper pole the gland is mobilized by division and ligation of the upper pole vessels (Fig. i) and middle thyroid vein. The inferior thyroid artery is ligated in continuity at a distance from the recturrent laryngeal nerve, which is identified and preserved. The parathyroid glands are also identified and preserved (or resected in cases of parathyroid disease). Thyroidectomy can now be performed. Meticulous haemostasis is carried out at each stage of the operation.
*Fellows interested in submitting papers for consideration with a view this series should first write to the Editor.
to
publication in
Cosmetic result in thyroid surgery An endotracheal tube is always used for administration of the anaesthetic. Large vessels are carefully ligated before division and wide use is made of diathermy, employing specially constructed forceps and scissors directly connected to the diathermy machine (Fig. 2). Great care is taken in coagulating
271
bleeding points during dissection. After complete haemostasis has been achieved two drainage tubes, one for each side, are inserted and fixed to the skin. The strap muscles are reconstituted, the platysma sutured, the skin closed with Kifa clips, and suction bulbs attached to the drainage tubes. A very small
FIG. I Good exposure of upper pole vessels facilitated by division of strap
muscles.
FIG. 2
Specially construc-
ted forceps and scissors directly connected to diat hermy machine.
272
Demetrios Chavatzas dressing is
;ii~!;.`J:E s2_
is
not
necessary
allowed
to
neck movements of the
two
limbs of
entirely,
it
cover
free.
are
ward and backward
'.
and the adhesive plaster so
strapping vertically assists this (Fig.
Results The amount of blood lost during the '.Vtion,
estimated
by weighing
usually less than
that
The arrangement
the
for-
opera-
swabs,
was
IOO ml. Postoperatively out
of 306 patients (see table) only 3 developed
haematoma and all
3
had subtotal thyroid-
hyperthyroidism. One had to be the theatre for ligation of the bleedone had a haematoma which was while the third had a small collec-
ectomy for taken to
ing vessel, drained, tion which resolved spontaneously. In all the other 303 patients haematoma formation was prevented by
the haemostatic
measures
taken.
An almost constant volume of 100-I50 ml of serosanguineous fluid was collected from the wound in the first 24 h by suction, after FIG. 3 Suction bulbs attached to drainage which the tubes were removed. As a result tubes. Note posit ion and size of dressing and constitutional recovery and wound healing adhesive plaster. were fast and cosmetic results excellent. Diagnoses and operations performed Diagnosis Diagnosis Hyperparathyroidism Diffuse toxic goitre
Multinodular goitre
Solitary nodules Papillary carcinoma Follicular carcinoma Anaplastic carcinoma Medullary carcinoma Thyroiditis
Papillary carcinoma (6) Plummer's disease (I) Cystic lesions (4) Thyroglossal fistula (i)
Operation ~~~Operation Subtotal parathyroidectomy Subtotal thyroidectomy Total thyroidectomy Partial thyroidectomy Thyroid lobectomy Thyroid lobectomy Total thyroidectomy Thyroid lobectomy Total thyroidectomy Subtotal thyroidectomy
Thyroid lobectomy Subtotal thyroidectomy Thyroid lobectomy Re-exploration Lobectomy Excision
No. of patients
3' 79 5
48 25
87 7 5 2 2 I I I
Excision
Total
306
Cosmetic result in thyroid surgery
273
Discussion haematoma formation and infection but also Despite the advanced knowledge and tech- enhanced the cosmetic results. niques of the present time, rates of haemaI wish to thank Mr Selwyn Taylor, consultant toma formation after thyroid or parathyroid surgeon to Hammersmith Hospital and the Royal surgery of 4-I 0% continue to be reported4. Postgraduate Medical School, for allowing me to In the present series 3 out of 306 patients study his patients and the Photographic Department developed haematoma a rate of less than for the illustrations. I
%/.
We have reason to believe that this low References rate of haematoma formation was largely I Harrison, T S (1970) Lebanese Medical Journal, 23, 537due to the meticulous haemostasis and suction drainage included in our standard technique. 2 Hall, R, Anderson, J, and Small, S A (I969) Fundamentals of Clinical Endocrinology. LonIt was interesting to note that almost always don, Pitman Medical. an amount of I00-I50 ml of serosanguineous fluid was evacuated by postoperative suction 3 Montgomery, D A D, and Welbourn, R B (I974) Medical and Surgical Endocrinology. London, drainage. Although rigid conclusions cannot Arnold. be drawn from this study, it is reasonable 4 Abraham, E, and Harrison, T S (I970) Lebanto assume that emphasis placed on haemoese Medical Journal, 23, 553. stasis and suction drainage not only reduced significantly the morbidity associated with 5 Rao, K M, and Taylor, S (I968) Lancet, 2, I57.
Cosmetic result
in
thyroid surgery
Demetrios Chavatzas MD MS Department of Surgery, Royal Postgraduate Medical School and Hammersmith Hospital, London
Summary In a series of 306 consecutive patients who had thyroid or parathyroid surgery for benign or malignant lesionis attention was paid to a technique in which particular emphasis was laid on meticulous haemostasis and suction drainage of the postoperative serosanguineous fluid. This not only reduced the morbidity associated with haematoma formation and infection but also contribuited to a good cosmetic result.
Introduction Haemorrhage and its complications associated with thyroid surgery appear so promninently in the surgical literature of the igth century that many surgeons, including Billroth', abandoned thyroidectomy. Other leading surgeons of the time such as Kocher and later Halsted, with their devotion and professional excellence, advanced the techniques and consolidated the place of this operation. Further progress has been made in more recent years by advances in our understanding of the physiology and vascular anatomy of the thyroid gland and the pathology and diagnosis of its disorders2,'. Nevertheless, among the complications postoperative bleeding with haematoma formation and infection continues to influence the results of the operation'.
I here report a series of 306 consecutive patients who had thyroid or parathyroid surgery for benign or malignant lesions and draw attention to the results of a technique in which particular emphasis is laid on careful haemostasis and suction drainage.
Technique The patient lies on the operating table with the neck extended'. After a Kocher collar incision, division of the platysma, and reflection of it with the skin flaps the strap muscles are identified, separated in the midline, and lifted with stay sutures, two for each side. With the sternomastoid retracted laterally, the ansa hypoglossi nerve is identified and preserved, while the strap muscles are divided between the stay sutures and the thyroid gland is thuis exposed. After a non-absorbable stay suture has been placed in each upper pole the gland is mobilized by division and ligation of the upper pole vessels (Fig. i) and middle thyroid vein. The inferior thyroid artery is ligated in continuity at a distance from the recturrent laryngeal nerve, which is identified and preserved. The parathyroid glands are also identified and preserved (or resected in cases of parathyroid disease). Thyroidectomy can now be performed. Meticulous haemostasis is carried out at each stage of the operation.
*Fellows interested in submitting papers for consideration with a view this series should first write to the Editor.
to
publication in
Cosmetic result in thyroid surgery An endotracheal tube is always used for administration of the anaesthetic. Large vessels are carefully ligated before division and wide use is made of diathermy, employing specially constructed forceps and scissors directly connected to the diathermy machine (Fig. 2). Great care is taken in coagulating
271
bleeding points during dissection. After complete haemostasis has been achieved two drainage tubes, one for each side, are inserted and fixed to the skin. The strap muscles are reconstituted, the platysma sutured, the skin closed with Kifa clips, and suction bulbs attached to the drainage tubes. A very small
FIG. I Good exposure of upper pole vessels facilitated by division of strap
muscles.
FIG. 2
Specially construc-
ted forceps and scissors directly connected to diat hermy machine.
272
Demetrios Chavatzas dressing is
;ii~!;.`J:E s2_
is
not
necessary
allowed
to
neck movements of the
two
limbs of
entirely,
it
cover
free.
are
ward and backward
'.
and the adhesive plaster so
strapping vertically assists this (Fig.
Results The amount of blood lost during the '.Vtion,
estimated
by weighing
usually less than
that
The arrangement
the
for-
opera-
swabs,
was
IOO ml. Postoperatively out
of 306 patients (see table) only 3 developed
haematoma and all
3
had subtotal thyroid-
hyperthyroidism. One had to be the theatre for ligation of the bleedone had a haematoma which was while the third had a small collec-
ectomy for taken to
ing vessel, drained, tion which resolved spontaneously. In all the other 303 patients haematoma formation was prevented by
the haemostatic
measures
taken.
An almost constant volume of 100-I50 ml of serosanguineous fluid was collected from the wound in the first 24 h by suction, after FIG. 3 Suction bulbs attached to drainage which the tubes were removed. As a result tubes. Note posit ion and size of dressing and constitutional recovery and wound healing adhesive plaster. were fast and cosmetic results excellent. Diagnoses and operations performed Diagnosis Diagnosis Hyperparathyroidism Diffuse toxic goitre
Multinodular goitre
Solitary nodules Papillary carcinoma Follicular carcinoma Anaplastic carcinoma Medullary carcinoma Thyroiditis
Papillary carcinoma (6) Plummer's disease (I) Cystic lesions (4) Thyroglossal fistula (i)
Operation ~~~Operation Subtotal parathyroidectomy Subtotal thyroidectomy Total thyroidectomy Partial thyroidectomy Thyroid lobectomy Thyroid lobectomy Total thyroidectomy Thyroid lobectomy Total thyroidectomy Subtotal thyroidectomy
Thyroid lobectomy Subtotal thyroidectomy Thyroid lobectomy Re-exploration Lobectomy Excision
No. of patients
3' 79 5
48 25
87 7 5 2 2 I I I
Excision
Total
306
Cosmetic result in thyroid surgery
273
Discussion haematoma formation and infection but also Despite the advanced knowledge and tech- enhanced the cosmetic results. niques of the present time, rates of haemaI wish to thank Mr Selwyn Taylor, consultant toma formation after thyroid or parathyroid surgeon to Hammersmith Hospital and the Royal surgery of 4-I 0% continue to be reported4. Postgraduate Medical School, for allowing me to In the present series 3 out of 306 patients study his patients and the Photographic Department developed haematoma a rate of less than for the illustrations. I
%/.
We have reason to believe that this low References rate of haematoma formation was largely I Harrison, T S (1970) Lebanese Medical Journal, 23, 537due to the meticulous haemostasis and suction drainage included in our standard technique. 2 Hall, R, Anderson, J, and Small, S A (I969) Fundamentals of Clinical Endocrinology. LonIt was interesting to note that almost always don, Pitman Medical. an amount of I00-I50 ml of serosanguineous fluid was evacuated by postoperative suction 3 Montgomery, D A D, and Welbourn, R B (I974) Medical and Surgical Endocrinology. London, drainage. Although rigid conclusions cannot Arnold. be drawn from this study, it is reasonable 4 Abraham, E, and Harrison, T S (I970) Lebanto assume that emphasis placed on haemoese Medical Journal, 23, 553. stasis and suction drainage not only reduced significantly the morbidity associated with 5 Rao, K M, and Taylor, S (I968) Lancet, 2, I57.
